Simplified point-of-care ultrasound protocol to confirm central venous catheter placement:A prospective study / 世界急诊医学杂志（英文）

@#BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%–93.5%) and specificity of 100% (95%CI 15.8%–100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10–29) and 32 minutes (IQR 19–45), respectively. CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Pre-hospital assessment with ultrasound in emergencies:implementation in the field / 世界急诊医学杂志（英文）

@#BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89％, 95％CI 67％–99％). Paramedics accurately recorded 17 cases of cardiac activity (100％, 95％CI 84％–100％) and 2 cases of cardiac standstill (100％, 95％CI 22％–100％). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Bedside Focused Ultrasound in Necrotizing Fasciitis: The “Black-hole Sign”.

Introduction: Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues, requiring prompt diagnosis and an aggressive management. The role of ultrasonography (US) in emergency setting for early diagnosis of NF was reported in literature, its accuracy being estimated 92% both before and without gas production. Presentation of the Case: A 65-year old man, with pulmonary metastasis from colonrectal cancer, treated with chemotherapy, complained of dyspnoea, fever and a dull pain in his left calf for 3 days. Skin was spared and no evidence of tactile alterations or edema was found. Bedside US focused on the painful zone revealed a small hypo-anechoic area in deep subcutaneous tissue with blurred contours and posterior shadowing (“black-hole sign”), referable to soft tissue necrosis. Thickness and hyperechogenicity of surrounding subcutaneous tissue, due to diffuse inflammatory infiltrate and edema, and thin distal fluid collection along the fascia, were also detected, without gas artifacts. Surgery debridement was performed, tissue cultures yielding Escherichia Coli, maybe due to the disruption of bowel mucosal wall. Discussion and Conclusion: Bedside goal-directed US performed by emergency physician can exclude alternative aetiologies to NF in severe localized pain of the lower extremity. The depiction of blurred focal changes in the soft tissue, configuring an US “black-hole sign” and referable to fat necrosis and suppurative infiltration, may represent the main early finding of NF, especially in the idiopathic form. Its identification should alarm physicians, inducing further investigations and close monitoring. The employment of bedside goal-directed US should be stressed in Emergency Department.

An overview of emergency ultrasound in the United States / 世界急诊医学杂志（英文）

BACKGROUND: As emergency ultrasound use explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field.METHODS: Approaches to education, scanning, documentation, and organization are also described.RESULTS: Machines have reduced in price and once purchased further material costs are low. Staffing costs in terms of training, etc have yet to be assessed, but indications from elsewhere are that these are low. Length of stay in the emergency department dramatically decreases, thus increasing patient satisfaction while maintaining an even higher standard of care.CONCLUSION: Emergency screening ultrasound is now a nationally accepted tool for the rapid assessment of the emergency patient.

The Utility of Emergency Ultrasound for Diagnosing Wrist and Ankle Injuries

PURPOSE: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available, such as disasters and military and space applications. However, the diagnosis of fractures is suggested by history and physical examination and is typically confirmed with radiography. As a alternative to radiography, we prospectively evaluated the utility of extremity ultrasound performed by trained residents of emergency medicine (EM) one patient with wrist and ankle extremity injuries. METHODS: Initially, residents of EM performed physical examinations for fractures. The emergency ultrasound (EM US) was performed by trained residents, who used a portable ultrasound device with a 10- to 5-MHz linear transducer, on suspected patients before radiography examination. The results of emergency ultrasound and radiography and the final diagnosis were recorded, and correlations among them were determined by using Kappa`s test. RESULTS: Thirty-nine patients were enrolled in our study. The average age was 36.6+/-19.3 years. There were radius Fx. (n=21), radius-ulna Fx. (n=1), ulna Fx. (n=1), and contusion (n=2) injuries among the wrist injury and lat.-med. malleolar Fx. (n=13), lat. malleolar Fx. (n=6), and med. malleolar Fx. (n=3) injuries among the ankle injury. Comparing EM US with radiography, we found the sensitivity, specificity, positive predictive value, and negative predictive value of EM US for Fx. diagnosis to be 100%, 66.7%, 97.3%, 100% and those of radiography to be 97.2%, 100%, 100%, and 75%, respectively. Kappa`s test for a correlation between the Fx. diagnosis of EM US and the final diagnosis of Fx was performed, and Kappa`s value was 0.787 (P = 0.004). CONCLUSION: EM US for Fx. can be performed quickly and accurately by EM residents with excellent accuracy in remote locations such as disaster areas and in military and aerospace applications. EM US was as useful as radiography in our study and had a high correlation to the final diagnosis of Fx. Therefore, ultrasound should performed on patients with extremity injury to determine whether extremity evaluation should be added to the FAST (focused abdominal sonography trauma) examination.

Emergency Ultrasonography in Unconscious Trauma Victims

BACKGROUND: The objective of this study was to determine the sensitivity, specificity of the ultrasound examination performed by emergency physicians in patients with altered mental state due to trauma. METHODS: From July 1998 until June 2000, a total number of 59 patients showing altered mental state were examined using emergency ultrasound at the time of primary survey. Their medical records were reviewed, and the interpretations of the emergency ultrasound were compared with the abdominal CT scan or clinical results. RESULTS: Of the 59 patients, 3 were excluded due to incomplete records. Among the 56 remaining patients, 9 patients had intra-abdominal problems. The sensitivity and specificity were 77% and 95.7%, respectively. Abdominal CT was not required in 41 (73.2%) patients. CONCLUSION: Emergency ultrasonography can serve as a useful screening tool in detecting free fluid in trauma victims who are not mentally alert.